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RA447.K41  D85       The  full-time  health 


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intI)fCitpofi^rttigork 
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The  Full-Time  Health  Officer  and 
Rural  Hygiene 


Address  delivered  at  the 

CoNPERBNCE  OF  State  Heai^th  Officers 

Louisville,  Ky.,  December  8,  1913 


BY 

LOUIS  L  DUBLIN,  Ph.D.,  Statistician 

Metropolitan  Life  Insurance  Company,  New  York 

1913 


The  Full-Time  Health  Officer  and  Rural  Hygiene 


The  State  of  Kentucky  presents  a  condition  of  lively  interest 
to  the  student  of  health  and  sanitation.  As  a  State,  it  is  among 
the  most  typically  American  in  the  country.  According  to  the 
1910  Census,  it  had  a  population  of  2,290,000,  of  whom  about 
98  per  cent,  were  native  born.  You  have,  therefore,  no  serious 
problems  of  assimilating  the  foreigner  in  your  midst  as  we  have 
in  the  East.  The  State  of  New  York,  for  example,  has  30  per 
cent,  of  its  total  population  foreign  born,  many  of  whom  have 
■  come  here  more  or  less  recently  from  Southern  or  Eastern  Europe. 
Furthermore,  over  75  per  cent,  of  your  population  live  in  rural 
territory  or  in  small  communities  of  less  than  twenty-five  hundred 
inhabitants.  Your  population  is,  therefore,  homogeneous.  You 
live  in  the  country  and  are  free  from  congestion  and  those  other 
unfavorable  conditions  of  industrial  and  urban  life  which  make  the 
health  problems  of  many  of  our  States  so  acute. 

The  situation  in  Kentucky  is  interesting  in  another  respect. 
You  have  upon  your  statute-books  a  good  health  law  which 
provides  the  necessary  machinery  for  your  health  work.  You 
have  also  a  model  law  for  the  registration  of  births  and  deaths, 
and  you  have  been  admitted  to  the  Registration  Area.  In  other 
words,  you  have  what  to  a  stranger  like  myself  would  appear 
to  be  a  very  favorable  condition  for  efficient  health  adminis- 
tration; namely,  a  population  not  too  large,  of  good  native  stock, 
thoroughly  imbued  with  American  ideals,  and  adequate  statutory 
provision  to  make  your  sanitary  control  both  sure  and  efficient. 

It  is,  therefore,  not  surprising  that  health  experts  look  to 
Kentucky  for  an  encouraging  example.  They  are  anxious  to 
learn  whether  you  are  ready  to  take  full  advantage  of  your  fine 
opportunities;  whether  you  will  make  continuous  advances  in 
health  conditions,  and,  perhaps,  be  able  to  solve  for  other  States 
some  of  the  vexing  problems  of  rural  hygiene.     Not  only  are 

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your  own  best  interests  involved  in  the  success  or  failure  of  your 
endeavors,  but  the  success  of  health  work  in  other  places  is  at 
stake.  Other  communities  will  be  guided  by  your  results  when 
providing  for  the  protection  of  their  people. 

Permit  me  to  review  the  essential  features  of  your  Health 
Law: 

In  the  main,  your  administration  is  based  on  the  county  as 
the  unit  of  organization.  The  county  boards  of  health  are  each 
clothed  with  responsibility  in  their  several  jurisdictions.  They 
have  power  to  establish  and  execute  sanitary  regulations  for  the 
control  of  disease;  to  establish  quarantine  and  erect  hospitals 
for  the  treatment  of  communicable  diseases.  The  county  boards 
must,  moreover,  report  to  the  State  board  at  least  every  three 
months  on  the  incidence  of  communicable  diseases  and  on  the 
general  sanitary  condition  of  the  county.  Each  county  board 
acts  through  an  executive  secretary,  who  is  the  health  officer  of 
the  county.  He  receives  compensation  from  the  county,  and 
holds  office  at  the  pleasure  of  the  local  board.  Apart  from  the 
officers  of  the  State  board  and  a  few  local  health  officers  in  each 
of  the  larger  cities,  the  county  health  officers  hold  the  key  to  the 
situation  in  your  State;  upon  their  efficiency  and  loyalty  depends 
the  health  progress  of  Kentucky. 

Kentucky  has  119  counties,  the  population  ranging  from 
about  4,000  in  Robertson  County  to  263,000  in  Jefferson  County. 
A  large  number  of  your  counties  have  much  the  same  land  area, 
with  a  population  density  of  about  57  inhabitants  per  square 
mile,  or  an  average  of  a  little  under  20,000  per  county.  This 
makes  a  favorable  unit  for  the  administration  of  rural  health 
work,  and  you  are  to  be  congratulated  upon  your  natural  advan- 
tages of  geographical  distribution.  The  one  question  that  arises 
in  my  mind,  however,  is  this:  To  what  extent  are  your  local 
county  organizations  fighting  machines  for  vigorous  adminis- 
tration? "Wliat  provisions  have  you  made  for  getting  the  work 
done  that  must  be  done?  To  what  extent  is  your  county  health 
officer  a  live  public  health  executive,  giving  all  his  time  and 
energy  to  the  public  service?  In  the  last  analysis,  this  is  the 
one  great  question  which  you  must  face  squarely  and  answer. 

The  problem  that  I  am  here  considering  is  not  a  new  one. 
Other  States  have  addressed  themselves  to  it,  and  to-day  it  is 
agreed  that  the  work  of  the  local  health  officer  must  measure 
up   to   certain   standards.     I   propose   to   review   some   of  these 

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standards,  not  because  you  are  not  familiar  with  them,  but  rather 
for  the  sake  of  emphasis.  In  this  way,  we  may  examine  our 
problem  comprehensively  and  draw  the  necessary  conclusions. 

1.  The  county  health  officer  must  be  a  full-time  official;  that 
is  essential.  In  certain  States  the  county  unit  has  not  been 
closely  followed,  and  where  the  county  is  too  small  or  too  sparsely 
settled  to  permit  the  services  of  a  full-time  official,  a  few  counties 
have  been  merged  for  health  purposes.  In  every  instance,  how- 
ever, the  full  time  of  a  competent  person  is  obtained  and  the 
geographical  arrangement  is  modified  to  suit.  I  do  not  know 
to  what  extent  your  distribution  of  population  in  certain  of  the 
smaller  counties  calls  for  a  similar  arrangement,  or  whether  your 
laws  would  permit  of  such  a  merging  of  county  lines ;  but,  whether 
they  do  or  not,  the  principle  is  clear.  The  health  officer  must 
be  one  whose  sole  interest  is  in  the  community,  to  the  exclusion 
of  private  interest,  be  it  his  own  or  that  of  private  individuals 
or  groups.  The  occasion  should  no  longer  arise  when  a  health 
officer  may  be  tempted  by  personal  considerations  to  neglect 
the  clear  dictates  of  commimity  needs.  You  know  only  too 
well  how  often  the  part-time  health  officer  who  has  a  private 
practice  to  maintain,  must  choose  between  the  performance  of 
public  duty  and  the  loss  of  his  practice.  This  situation  should 
not  arise.  He  should  never  find  it  necessary  to  compete  with 
those  whom  it  is  his  sworn  duty  to  supervise. 

2.  The  county  health  officer  should  be  well  trained  in  the 
modern  science  of  sanitation  and  public  health.  The  average 
practising  physician  is  not  well  enough  equipped,  as  a  rule,  to 
administer  a  progressive  health  office.  The  protection  of  the 
public  health,  as  now  conceived,  is  a  science  with  its  own  data 
and  formulae.  The  larger  medical  schools,  such  as  those  at 
Harvard  and  at  the  University  of  Michigan,  for  example,  have 
organized  special  post-graduate  courses  leading  to  the  degree  of 
Doctor  of  Public  Health.  It  will  be  a  great  day  in  American 
public  health  affairs  when  medical  officers  will,  as  a  class,  qualify 
by  study  in  such  post-graduate  courses  for  their  arduous  duties. 
But  experience  is  also  a  good  school,  and  the  health  officers  here 
assembled  have  been  trained  in  the  severest  of  schools.  Ulti- 
mately, provision  will  undoubtedly  be  made  in  your  State  for  the 
exclusive  appointment  of  holders  of  the  Diploma  in  Public  Health. 
May  I  suggest  that  you  direct  your  energies  toward  your  personal 

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improvement,  through  study,  to  quaHfy  for  the  distinctive  degree 
of  your  profession  ? 

3.  The  tenure  of  office  of  the  health  officer  should  be  co- 
extensive with  his  efficient  service.  The  successful  health  officer 
is  made,  not  bom.  With  a  proper  background  of  training,  ever}^ 
year  of  added  experience  makes  him  a  more  useful  servant  of 
the  State.  The  health  officer  should,  therefore,  be  assured  of  a 
continuous  tenure  of  office.  He  should  in  no  way  be  a  pawn  in 
the  political  game.  A  period  of  six  to  eight  years  has  been  sug- 
gested as  a  sufficient  term.  Health  officers  who  have  made  good 
should  then  be  considered  for  reappointment,  although  the  State 
may  reserve  the  right  to  dismiss  in  shorter  time  those  who  are 
incompetent  or  neglectful  of  their  duties.  There  is  no  better 
reason  for  removing  good  health  officers  than  there  is  for  changing 
other  public  servants  whose  work  is  necessarily  continuous,  and 
who,  in  the  first  instance,  are  properly  chosen. 

In  view  of  these  requirements  it  should  hardly  be  necessar>' 
to  point  out  that  health  officers  must  be  reasonably  compensated 
for  their  services.  We  have  already  assumed  that  the  man 
chosen  for  the  place  is  the  one  in  a  hundred  best  qualified  by 
training.  Surely,  if  his  full  time  is  required,  his  compensation 
must  be  sufficient  to  attract  him  and  to  keep  him  in  the  service 
without  inflicting  any  hardship  upon  him  or  his  family.  It 
is  folly  to  set  high  standards  and  to  make  them  impossible  of 
attainment  because  of  inadequate  compensation  or  uncertainty 
of  tenure.  Health  laws  may  as  well  not  exist  if  they  are  not 
properly  enforced  because  of  inadequate  appropriations.  A 
county  health  officer,  having  in  his  safekeeping  20,000  lives, 
cannot  maintain  himself  on  an  annual  allowance  of  a  few  hundred 
dollars.  It  is  not  for  me  to  determine  what  you  shall  pay,  but 
your  salaries  must  be  adequate  to  attract  able  men  and  to  maintain 
them  in  a  state  of  comfort  consistent  with  their  important  duties. 

I  say  this  guardedly.  I  am  one  of  those  who  believe  in  govern- 
mental economy.  I  have  always  urged  that  the  efficiency  tests 
which  have  been  introduced  into  modem  business  must  also  be 
applied  to  the  expenditure  of  public  funds.  It  is  because  of  this 
very  conviction  that  I  maintain  that  communities  must  tax 
themselves  liberally  to  support  high  standards  of  health  adminis- 
tration; for  it  is  the  best  economy  in  the  end.  The  chief  assets 
of  a  community  are  the  life  and  the  health  of  its  citizens.  We  are 
realizing  more  and  more  that  life  and  health  are  within  our  control. 

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Changes  in  century-old  conditions  are  being  brought  about  every- 
where and  the  marvels  of  modern  medicine  are  visible  on  all  sides. 

Permit  me  to  point  out  more  definitely  the  character  of  the 
return  that  awaits  you  on  your  investment  in  full-time  health 
oflBcers.  In  spite  of  the  fact  that  yours  is  a  rtu-al  State,  you  are 
by  no  means  free  from  the  ravages  of  tuberculosis.  In  the  year 
1911,  5,293  deaths  from  this  disease  were  reported  in  your  State, 
which  is  equivalent  to  a  rate  of  229.3  per  hundred  thousand.  In 
the  Registration  States,  which  include  the  centers  of  congeston, 
the  rate  was  155.6  per  hundred  thousand.  A  clear  duty  is  there- 
fore at  your  door,  namely,  to  reduce  your  tuberculosis  mortality. 
This  would  be  the  first  task  of  a  full-time  health  officer.  If 
in  five  years  the  rate  from  this  disease  be  reduced  to  what  it  is 
in  the  Registration  Area  to-day,  about  1,700  lives  will  be  saved 
annually  for  the  State  of  Kentucky.  The  victims  are  largely 
men  and  women  in  their  prime,  whose  money  value  to  the  State 
would  be  enough  to  compensate  for  the  cost  of  the  additional 
health  work. 

Your  typhoid  problem  is  equally  urgent.  In  1911,  your 
death  rate  from  this  disease  was  46.3  per  hundred  thousand,  as 
against  20.4  in  the  Registration  States.  In  this  respect  your 
experience  is  parallel  to  that  of  other  rural  communities,  and 
clearly  indicates  the  many  sanitary  dangers  incident  to  life  in  the 
country.  Typhoid  fever  is  always,  to  the  health  engineer,  an 
unerring  signal  directing  him  toward  polluted  water  supplies, 
infected  food  products,  and  unsupervised  typhoid  carriers.  These 
are  a  constant  menace  to  the  entire  State  through  their  effect  on 
milk  and  other  food  supplies.  All  of  these  sources  of  typhoid 
infection,  including  the  disposal  of  dangerous  waste  products, 
lend  themselves  to  the  concerted  efforts  of  modem  sanitary  science. 
Indeed,  no  disease  has  shown  such  a  ready  response  to  control  as 
this  preventable  filth  disease.  What  is  every  one's  concern  is  no 
one's.  The  full-time  health  officer,  supported  enthusiastically  by 
his  community,  would,  in  the  course  of  his  first  administration, 
earn  many  times  his  cost  in  reducing  sickness  and  death  from  this 
cause  alone. 

The  full-time  health  officer  would,  of  course,  participate  in 
other  lines  of  activity.  The  influence  of  his  work  would  soon 
become  manifest  in  reduced  rates  of  sickness  and  death  for  the 
other  preventable  diseases.  The  records  put  at  my  disposal 
show  that,  in  1912,  39.5  per  cent,  of  all  your  deaths  were  of  this 

5 


character.  In  other  words,  about  12,000  deaths  occurred  in  the 
course  of  the  year  which  could  have  been  controlled  and  perhaps 
indefinitely  postponed  if  proper  sanitary  facilities  had  been  at 
work  during  the  past  few  years.  In  no  one  respect,  however, 
would  the  service  of  the  full-time  health  officer  be  more  con- 
structive and  remimerative  to  a  community  than  in  this  active 
participation  in  what  we  now  call  "Child  Hygiene."  In  the 
larger  cities  throughout  the  country  this  phase  of  health  adminis- 
tration is  becoming  permanently  established.  In  New  York, 
where  I  am  best  acquainted  with  its  results,  there  is  no  division 
of  the  health  department  which  has  aroused  greater  enthusiasm 
among  experts  than  the  Division  of  Child  Hygiene.  It  would  be  a 
function  of  the  full-time  county  health  officer  to  work  in  co- 
operation with  the  school  authorities  of  his  community,  and  to  see 
that  each  child  in  his  jurisdiction  is  examined  at  least  once  annually. 
It  is  during  the  period  of  child  life  that  the  foundation  is  laid  for 
the  physique  which  will  determine  largely  the  usefulness  and 
longevity  of  the  future  citizen.  If  there  were  no  better  excuse 
than  the  need  for  some  local  authority  to  cany^  on  intelligent  and 
modern  child  hygiene  work  in  each  community,  you  would  be 
justified  in  appointing  a  full-time  health  officer  for  this  purpose. 

The  full-time  health  officer  would  also  be  of  great  service 
as  the  representative  of  the  State  health  board  in  overseeing  the 
registration  of  births,  deaths  and  the  occurrence  of  communicable 
diseases  in  each  county.  Fortunately,  the  health  law  of  Kentucky 
clearly  provides  for  the  reporting  of  epidemic  and  communicable 
diseases  to  the  local  boards  of  health.  Your  county  health  officers 
are,  moreover,  under  obligation  by  law  to  see  that  all  the  cases 
are  registered,  and  in  turn  to  notify  the  vState  office.  In  spite  of 
the  importance  of  this  work,  it  is  clear  that  without  adequate 
administrative  supervision,  it  is  sure  to  be  neglected.  The  reports 
of  your  county  health  officers  compel  me  to  believe  that  this  is 
the  condition  of  morbidity  registration  at  the  present  time  in 
your  State,  except,  perhaps,  in  the  larger  cities  where  tuberculosis 
and  typhoid  fever  are  carefully  handled.  The  morbidity  reports 
of  your  county  health  officers  are  extremely  vague  and  indefinite. 
With  full-time  health  officers  to  do  this  important  work  scientific- 
ally and  effectively,  the  State  would  not  be  deprived,  as  it  is  at 
present,  of  a  most  useful  agency  of  sanitation. 

An  examination  of  your  annual  reports  has  raised  a  number  of 
other  questions  in  my  mind  which  I  submit  frankly  for  your  atten- 

6 


tion  and  discussion.  I  have  already  remarked  that  your  death  rate 
from  tuberculosis  is  relatively  high;  for  pulmonary  tuberculosis 
alone  your  figure  for  1911  was  200.4  per  hundred  thousand,  or  15.2 
per  cent,  of  the  total  deaths  for  the  year.  In  the  Registration 
States  the  corresponding  figures  are  134.7  per  hundred  thousand 
and  9.7  per  cent,  of  the  total  deaths.  In  other  words,  you  have  a 
high  tuberculosis  rate  coupled  with  a  low  general  death  rate. 
As  you  know,  the  death  rate  from  tuberculosis  presents  a  fairly 
constant  relation  of  about  10  per  cent,  to  the  total  deaths  in 
most  communities  where  satisfactory  registration  conditions 
prevail.  In  view  of  this  fact,  two  questions  arise,  namely,  either 
your  tuberculosis  rate  is  inordinately  high,  or,  what  is  perhaps 
more  likely,  you  are  not  registering  a  considerable  number  of 
your  actual  deaths.  A  death  rate  of  200  per  hundred  thousand 
from  pulmonary  tuberculosis  should  ordinarily  show  a  general 
death  rate  of  about  20  per  thousand,  and  not  13,  as  your  reports 
indicate.  In  this  connection,  I  need  hardly  point  out  how  valu- 
able full-time  health  officers  would  be  to  your  State  health  de- 
partment and  to  your  Legislature,  in  putting  at  their  disposal  a 
complete  accounting  of  all  the  occurrence  of  disease  and  death 
which  come  under  their  jurisdiction.  You  would  thus  be  in  a 
position  to  see  annually  what  your  added  expenditures  for  health 
work  had  accomplished  in  the  conservation  of  health  and  life. 

It  was  proposed  by  Dr.  Heizer,  your  State  Registrar  of  Vital 
Statistics,  that  I  also  discuss  the  economic  saving  that  would 
accrue  to  your  State  through  the  employment  of  full-time  health 
officers  in  the  lowered  cost  of  life  insurance.  I  believe  that 
this  is  the  least  interesting  phase  of  the  discussion.  Insurance 
costs  are  naturally  dependent  upon  the  death  rates  the  com- 
panies experience.  If  your  new  programme  results,  as  it  should, 
in  reduced  death  rates,  certain  appreciable  savings  will  undoubtedly 
be  experienced  by  the  companies  operating  in  Kentucky.  It 
has  been  the  constant  policy  of  insurance  companies  to  keep  in 
close  touch  with  the  life  and  health  conditions  prevailing  in  their 
territory,  and  in  every  case  to  accommodate  their  rates  to  the 
changing  mortality.  Life  insurance  is  the  one  essential  commodity 
in  modem  life  the  cost  of  which  has  not  risen  during  the  last 
twenty  years.  Further  reductions  will  undoubtedly  follow  in 
the  wake  of  improved  living  standards.  Indeed,  the  history  of 
insurance  is  the  best  index  of  the  constant  increase  in  the  average 
span  of  life  which  has  been  observed  during  the  last  century. 

7 


There  is  still  one  other  source  of  communal  gain  which  goes 
hand  in  hand  with  high  health  standards.  I  refer  to  the  added 
commercial  value  of  locations  in  which  good  health  conditions 
prevail.  vSuch  communities  have  added  attractiveness  for  pur- 
poses of  residence  and  industrial  development.  Persons  who 
contemplate  a  change  of  residence  are  naturally  attracted  to  places 
where  they  can  be  assured  of  a  good  water  supply  and  other 
safeguards  to  health.  Nowadays,  industrial  concerns  are  located 
only  where  a  large  nuniber  of  employees  can  be  housed  with 
safety.  As  a  result  of  these  things,  land  values  rise  and  an  impetus 
is  given  to  the  general  prosperity  of  the  community. 

In  closing,  let  me  once  more  urge  upon  you  that  life  and 
health  are  both  largely  purchasable.  It  is  only  in  the  present 
day  and  generation  that  we  realize  the  full  significance  of  the 
situation,  and  feel  the  obligation  that  it  places  upon  us.  It  lies 
with  us  whether  our  communities  shall  rise  up  in  their  strength 
to  work  and  accomplish  their  full  possibilities,  or  whether  we 
shall  continue  to  pay  a  constant  tribute  with  human  life  through 
our  indifference  and  neglect.  Public  health  is  no  longer  an 
indi\ndual  matter.  We  must  protect  ourselves  by  keeping  watch 
over  all.  This  is  the  new  order  of  living,  and  a  new  public  health 
with  rigid  standards  and  methods  has  come  to  stay.  The  full- 
time  health  oflicer  is  the  keystone  in  the  arch  of  the  new  public 
health  service.  You  are  at  a  crucial  point  in  your  health  ad- 
ministration. I  am  sure  that  you  will  take  good  counsel  and 
that  your  decision  will  be  a  source  of  inspiration  to  other  com- 
munities who  have  not  as  yet  seen  the  light. 


S!61 


COLUMBIA  UNIVERSITY 

'I'his  bQQ.k  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C2B'63B)M50 

RA447.K41 


D85 


DulDlin 


